Provider Demographics
NPI:1942232087
Name:WYRICK, LENORE P (RN, FNP)
Entity Type:Individual
Prefix:
First Name:LENORE
Middle Name:P
Last Name:WYRICK
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 WHITNEY CIR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-4525
Mailing Address - Country:US
Mailing Address - Phone:903-831-4253
Mailing Address - Fax:
Practice Address - Street 1:3333 POTOMAC AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3513
Practice Address - Country:US
Practice Address - Phone:903-792-3787
Practice Address - Fax:903-792-0446
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX573207363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87N848Medicare ID - Type Unspecified